IC10 Schizophrenia & Psychosis Flashcards
(35 cards)
What are the symptoms of schizophrenia?
- Positive symptoms (hallucinations/delusions)
o Hallucinations – perceptual experiences without stimulations
o Delusions – fixated on a belief that is not true - Negative symptoms (great loss of interest)
- Functional impairment
- Protracted Psychosis – last for a long time, about >6 months and will not stop
What needs to be ruled out before diagnosing someone as schizophrenic?
Rule out:
- organic disorders
o e.g. iatrogenic causes,
o psychosis related to alcohol / psychoactive substance misuse such as BZD, anti-depressants, corticosteroids, CNS stimulants - mood/affective disorders e.g. depression, bipolar disorder, mania, post-partum psychosis
What is the cause of schizophrenia (patho)?
- dysregulation of 5-HT, Dopamine and glutamate functions
What is the DSM-5 criteria for schizophrenia?
DSM- 5 criteria for schizophrenia:
-
2 or more of the following for at least 1 month
a. Hallucination
b. Delusions
c. Disorganized speech
d. Grossly disorganized / catatonic behaviour (reacts very little)
e. Negative symptoms - Social/ work functioning significantly decreased
- S&S continued for at least 6 months
- Disorder not due to medical disorder or substance use
What are the non-pharm management?
Non-pharmacological Management:
- Cognitive Behavioral Therapy (CBT) ?
a. Help patients learn how to manage problems by changing the way they think and behave
b. Used together with medications and family interventions - Supportive counselling
- Social skill therapies
- Rehab
- Vocational training etc.
- Electroconvulsive therapy (ECT)
a. For treatment-resistant schizophrenia
What is the drug class that we use for schizophrenia?
Anti-psychotics
What does antipsychotics help with? How is it better than the BZDs? What is its place in therapy for schizophrenia (long term or short term)?
Pharmacological Management: Anti-psychotics (aka Thought Organizer)
- Tranquilizes without impairing consciousness (vs BZDs which knocks them out) and without causing paradoxical excitement (vs BZDs which causes more agitation)
- Action:
o Relieve symptoms of psychosis (e.g. thought disorder, hallucinations and delusions) + prophylaxis
o Long term treatment necessary since without it most will relapse
Why are relapse often delayed when you stop antipsychotic meds for schizophrenia?
Relapse are often delayed after cessation of treatment
- Because adipose tissue act as a depot reservoir after chronic regular use of antipsychotics. Antipsychotics are stored in fat cells, then diffuses back into bloodstream after treatment cessation
What pathway does antipsychotics work on thus giving it its efficacy?
Which symptom(s) does it work on?
Efficacy:
- Mesolimbic pathway – block D2 receptors thus reduce +ve symptoms of schizophrenia
- FGA & SGA –> both can improve +ve symptoms via D2 antagonism in mesolimbic tract
- SGA only –> may also improve -ve symptoms via 5-HT2 antagonism
What are the pathways that antipsychotics affect that causes them to have their ADRs?
ADRs:
- FGAs –> EPSE (more than SGAs)
Nigrostriatal pathway (body movement) – block dopamine receptors thus EPSE - SGAs
Metabolic SE (more than FGAs except Aripiprazole, brexpiprazole, Cariprazine, lurasidone, ziprasidone)
SGAs ending with “-ines” e.g. clozapine, olanzapine, quetiapine, generally more sedating & weight gain
Tuberoinfundibular pathway (prolactin) - hyperprolactinemia
o Mesocortical pathway (higher order thinking and executive functions) – block Dopamine thus results in -ve symptoms of schizophrenia
Which antipsychotics have more sedating and weight gain SE?
SGAs ending with “-ines” e.g. clozapine, olanzapine, quetiapine
Which 2nd gen antipsychotics do not have metoblic SE?
Aripiprazole, brexpiprazole
What is the PK of antipsychotics?
PK of PO antipsychotics
- Most have short Tmax of 1-3hrs except Brexpiprazole, aripiprazole, olanzapine
- Most have long t1/2 thus QD, but some need to be given in divided doses due to their high risk of causing hypotension and seizures e.g. CPZ, clozapine, quetiapine, Amisulpride
Which antipsychotics need to be given in divided doses?
CPZ, clozapine, quetiapine, Amisulpride
List exmaples of high potency and low potency antipsychotics.
- High potency antipsychotics: haloperidol, olanzapine, risperidone
- Low potency antipsychotics: chlorpromazine, Amisulpride, clozapine, quetiapine
What is the duration of the antipsychotics when we first initiate it before we can see results?
- Duration of antipsychotic trial: at least 2-6 weeks at therapeutic dose; clozapine needs 3 months
What are the adjunctive medications we can give to antipsychotics?
Adjunctive treatment: BZD (help w agitation/sleep), Anti-depressant (for depression)
Define treatment resistant schizophrenia.
What can we give to treat it?
What do we need to monitor?
Treatment Resistance Schizophrenia (TRS)
- Not responsive to at least 2 adequate trials of anti-psychotics, of which one is a SGA
- Duration of antipsychotic trial: at least 2-6 weeks at therapeutic dose; clozapine needs 3 months
-
Clozapine is licensed drug of choice for TRS
o Monitor baseline and periodic FBC due to risks for agranulocytosis - If still no response, clozapine + FGA/SGA/ECT
What is the treatment / algorithm for acute stabilization of schizophrenia?
Acute Stabilization Phase
- Goal: minimize acute symptoms, minimize threat to self and others, reduce agitation, aggression, hostility, improve sleep
- If acutely agitated/aggressive, patient cooperative:
o 1st: de-escalate
o 2nd: consider oral anti-psychotics +/- BZD
Oral Lorazepam 1-2mg OR
Oral Antipsychotic e.g. PO Haloperidol + ECG, PO Risperidone, PO Quetiapine, PO Olanzapine - 3rd: if uncooperative, refuse or impossible to administer oral meds
Consider fast acting IM alternatives + Monitoring
–> IM Haloperidol 5mg + ECG + IM Lorazepam 2mg** OR
–> **IM Haloperidol + ECG + IM Promethazine(anti-histamine)
o 4th: Monitor for treatment-emergent ADRs:
Dystonia, pseudo-parkinsonian SE e.g. EPSE –> treat accordingly e.g. PO/IM Benztropine 2mg (anti-cholinergic)
Others: BP, HR, RR, Oximetry, Tdegree, pain, I/O chart, hydration status
o IF catatonia: give BZD e.g. PO/IM Lorazepam
What to do during the stabilization/maintenance phase?
What to give when patients are non-adherent?
Stabilization & Maintenance Phase
- Goal: minimize/prevent relapse, promote adherence, maintain baseline functioning
- Monitor and manage ADRs
- If poor adherence to PO medications, or if patients prefer IM consider:
o IM Long-acting anti-psychotics (LAI) e.g. IM Haloperidol Deaconate, IM risperidone long acting (need to add on PO risperidone during 1st 3wks)
o Community Psychiatric Nurse Referral
o Patient and family education
How to manage dystonia/tremors/rigidity? What drug usually causes this?
a. SE: Dystonia, tremors/rigidity
i. Common in: high potency e.g. Haloperidol
ii. Management:
1. Anticholinergics e.g. benztropine, diphenhydramine;
2. OR BZDs to relax muscles
3. OR switch to lower potency anti-psychotics/SGAs e.g. Quetiapine, sulpride
How to manage akathisia? What drugs usually cause this?
b. SE: Akathisia (restless)
i. Common in: high potency antipsychotics e.g. haloperidol
ii. Management: Clonazepam and/or propranolol (beware of bradycardia, hypotension); OR switch to SGA/lower potency anti-psychotics
How to manage tardive dyskinesia? What drugs causes this?
c. SE: Tardive Dyskinesia (irreversible if detected late in advanced stages)
i. Common in: FGAs, worsens with anti-cholinergics
ii. Management: stop any anticholinergics AND switch to low potency SGA; OR treat with valbenazine
How to manage hyperprolactinemia? What drugs usually cause this?
- Hyperprolactinemia
a. SE: breast pain, swelling, lactation, gynecomastia
b. Common in: FGAs, paliperidone, amisulpride
c. Management: switch to aripiprazole, OR dopamine agonist e.g. bromocriptine
